Feeding and swallowing impairments (dysphagia)

What is dysphagia?

Dysphagia is the term used to describe difficulties with feeding and/or swallowing.

It is pronounced "dis.fay.jeeya"

Speech therapists and dysphagia

 

Speech therapists work with people who have feeding and/or swallowing problems. Many years ago, speech therapists working with children with cerebral palsy taught them to eat because no one else was doing this, and there was a notion that because we knew about oral function,  we would know about how to teach children to eat. Our role in the treatment of dysphagia grew from there, and for at least 30 years, the treatment of dysphagia - feeding and/or swallowing problems - has been in the scope of practice of the speech therapist. We are involved in the identification, assessment, treatment as well as prevention of dysphagia, in persons of all ages.

Today, the treatment of dysphagia is highly specialised, and not all speech therapists work with feeding and/or swallowing problems. However, all undergraduate courses in South Africa include courses on dysphagia and both academic competency and clinical competency in the assessment, management and prevention of dysphagia are essential in order to qualify as a speech therapist.

We always work in professional teams, including medical doctors, nurses, occupational therapists, radiologists, dieticians,physiotherapists, and of course, with families who form the centre of the team.

Signs and symptoms of feeding and/or swallowing problems

There are many signs that individuals can show that indicate that they have feeding and/or swallowing problems. Here are some lists but they are not all inclusive.

Signs of dysphagia in very young babies

  • baby takes long to feed

  • baby gulps when feeding

  • baby does not latch onto the breast

  • baby cannot suck

  • baby goes blue when drinking

  • baby stops and takes breaths while feeding

  • baby loses milk out of mouth while feeding

  • baby chokes while feeding

  • milk comes out of nose while feeding

  • baby cries after a feed

  • baby seems hungry after a feed

  • baby burps excessively after a feed

  • baby cannot coordinate drinking, breathing, and sucking

  • baby cries if put down after feeding

  • baby vomits after feeds

  • milk comes up after a feed

  • have to hold baby upright after a feed

  • baby cannot breast feed but can only bottle feed

  • baby bites mom's nipples

  • mom is sore during and after a feed

Signs of dysphagia in older children and adults

  • difficulty chewing

  • difficulty moving the food around the mouth

  • loss of food or liquid out of the mouth

  • dry mouth (no or little saliva)

  • difficulty swallowing

  • choking after swallowing

  • wet voice quality after swallowing

  • feeling of something stuck in the throat after swallowing

  • no appetite

  • loss of taste

  • funny smell when eating

  • metallic taste in mouth during or after eating

Signs of dysphagia in babies in the first year of life

  • baby seems hungry all the time

  • baby does not sleep

  • baby wakes up crying often during the night

  • difficult to give the baby solid food

  • difficulty for the baby to tolerate food that is not totally smooth

  • baby can only tolerate thick smooth food e.g. yogurt consistency

  • baby chokes

  • baby coughs during a meal

  • baby vomits after a meal

  • baby loses food out of the mouth while feeding

  • baby bites down on the spoon

  • baby loses saliva while feeding

  • baby drinks huge amount of formula

  • baby wants to breast feed all the time

  • avoiding foods

  • picky eating

  • fussy eater

  • always eating

  • refusing to eat

  • underweight

  • overweight

  • cannot learn to use a spoon

  • does not want to touch food

  • does not want to have bits of food in the mouth

What causes dysphagia?

There are many, many reasons why individuals experience feeding and/or swallowing problems.

Structural problems associated with feeding and/or swallowing problems

  • cleft lip and/palate

  • blockage at the back of the nose (choanal atresia)

  • small jaw (micrognathia)

  • underdevelopment of the larynx (laryngomalacia)

  • very high arched palate

  • tongue tie

  • post oral surgery

  • post surgical re-sectioning in the mouth and/or neck

  • vascular abnormalities

  • tumours

  • thyroid problems

Neurological problems associated with feeding and/or swallowing problems

  • cerebral palsy

  • traumatic brain injury

  • progressive neurological diseases

  • paralysis of facial muscles

  • loss of sensation in jaw, tongue or lips

  • tremors in jaw

  • stroke

  • cranial nerve problems

Cognitive problems associated with feeding and/or swallowing problems

  • Intellectual disability

  • Alzheimer's disease

  • Dementia

  • Confusion after stroke

  • Disorientation

Behavioural problems associated with feeding and/or swallowing problems

  • Anxiety

  • Food aversions

  • Fear

Diseases associated with feeding and/or swallowing problems

  • Thrush

  • Rotten teetch

  • Herpes

  • Shingles

  • Mouth ulcers

 

How do we evaluate dysphagia?

The first thing to do is consult with a medical doctor or a speech therapist. Dysphagia is a medical condition. The medical doctor will refer you to a speech therapist, or the speech therapist will refer you to a medical doctor who knows about dysphagia. The doctors and therapists, including the nurses and dieticians,  will form the multi-disciplinary team.

The doctor and/or speech therapist will examine the individual, and will be likely to refer the individual for additional tests.

The examination will include an evaluation of the person as well as an observation of the person eating and drinking.

Additional tests for dysphagia include the following:

A modified barium swallow study (MBS):

This procedure is a special x-ray conducted by a speech therapist and a radiologist. It involves an x ray of a person while he or she is eating and swallowing foods of different textures mixed with barium. The x ray is  motion videoed so that the speech therapist and the radiologist can watch the movement of the food through the mouth and into the stomach.

Here is a video of MBS (not for viewers who cannot handle medical stuff!)

https://www.youtube.com/watch?v=xu_YYOAlZEw

Flexible endoscopic evaluation of swallowing (FEES): In South Africa, this is always conducted by a medical doctor, usually an ENT. A tube that is attached to a digital camera (this is called an endoscope) is placed through one nostril and is pushed into the back of throat so that the camera can film down the throat, and the doctor and speech therapist watch what happens to food as it is swallowed.

You can watch a YouTube video of FEES here (not for viewers who can't deal with medical images!!!)

https://www.youtube.com/watch?v=GMS8dEtfis4

Transnasal esophagoscopy (TNE):

The medical doctor (usually an ENT or gastroenterologist) may want to look into the food pipe (the oesophagus) and to do so, he or she will push an endoscope (the tube attached to a small digital camera) up the nose, and down the throat into the oesophagus.

Manometry:

This is a special test that measures the pressure in the food pipe (oesphagus) as we swallow.

pH monitoring:

This is a special procedure that measures the production of acid in the stomach. It determines how long the acid stays in the stomach. This test is usually done by a gastroenterologist.

What do these dysphagia procedures tell us?


They tell us about the passage of food from the lips to the stomach. They tell us about how efficient the movements of the mouth are; how well the tongue moves the food to the back of the throat; how quickly swallowing is triggered; whether food gets stuck in the throat after swallowing; whether food goes down 'the wrong way' i.e.the airway (aspiration); whether food moves easily and quickly into the stomach; whether the stomach acid is regular; and so on. There is no way that we can determine all of this information unless we do these special procedures.

We have SIGNS and SYMPTOMS of dysphagia that alert us to the risk of problems, but only these procedures are reliable.

Speech therapy and dysphagia

Speech therapists identify, assess, treat and prevent dysphagia

We have a number of techniques and approaches to help to overcome, reduce or minimise dysphagia.

Speech therapy that addresses dysphagia can  include the following:

  • Modify consistency of food.

Sometimes, people are not able to eat or drink foods of different textures, and we find that they can eat safely and efficiently if we change the thickness and 'runniness' of the foods that they eat.

  • Modify consistency of fluids.

Sometimes, liquids are too runny for a person to manage, and aspiration can occur. We very carefully monitor and change the thickness and 'runniness' of liquids.

 

  • Modify feeding strategies and swallow techniques

We have a whole lot of techniques that we can teach people to use while they are eating and drinking that help feeding and swallowing.
 

  • Modify posture.

Very often modifying the body posture of the individual can go a long way to helping make eating safe and efficient. We often work with physiotherapists and occupational therapists to modify posture.

 

  • Improve oral hygiene.

Many people with feeding and swallowing problems have problems with oral hygiene - which involves much more than tooth brushing. It is sometimes difficult to brush teeth; often there is food left over in the mouth; sometimes there is not enough saliva... and all kinds of other problems that lead to oral hygiene issues. Speech therapists contribute to ensuring that people with dysphagia maintain good oral hygiene.

  • Increase confidence and reduce fear of choking

It is so easy to become scared of eating or drinking. A sore throat can stop one from wanting to eat. Fear of choking can make one avoid eating. Speech therapists have a number of strategies that we use to encourage anxiety-free eating and swallowing.

  • Educating caregivers and parents

Many people are dependent to some extent on being fed by others. It is absolutely crucial for carers to be trained to feed the person with dysphagia. Training caregivers is a major role of the speech therapist in relation to managing dysphagia.

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